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Found 206 results
  1. News Article
    Seven integrated care systems and one ambulance trust have been placed in ‘intensive support’ because of their performance against urgent and emergency care metrics. NHS England launched the new intervention regime for emergency care earlier this year to measure progress against the urgent and emergency care recovery plan. The most troubled systems and organisations are now placed in a first “tier” and will receive central support from NHSE. Other systems requiring support from NHSE regional teams are placed in a secondary tier. This tiered approach is already in place for cancer and elective performance. Support will include help with analytical and delivery capacity, “buddying” with leading systems and “targeted executive leadership”. Read full story (paywalled) Source: HSJ, 7 June 2023
  2. News Article
    The mother of a seriously ill boy said she was "very alarmed" when a doctor at an under-fire children's ward admitted they were "out of their depth". In October, Carys's five-year-old son Charlie was discharged from Kettering General, but she returned him the next day in a "sort of lifeless" state. She said it seemed "quite chaotic" on Skylark ward before he was transferred to another hospital for further tests. Since the BBC's report in February that highlighted the concerns of parents with children who died or became seriously ill at the hospital, dozens more have come forward. In April, Care Quality Commission (CQC) inspectors rated the Northamptonshire hospital's children's and young people's services inadequate. Among the findings, inspectors said "staff did not always effectively identify and quickly act upon patients at risk of deterioration". Read full story Source: BBC News, 6 June 2023
  3. Content Article
    Context Poor care can have a traumatising effect at any time, but the consequences in maternity care are particularly profound. The death of a baby is a devastating loss for any family. As one bereaved mother put it: “When your baby dies, it’s like someone has shut the curtains on life, and everything moves from colour to darkness.”[1] It is all the more perplexing that this area of care has seen recent declines in indicators of quality and safety. There have been repeated investigations into maternity services, with repeated recommendations for improvement. Dr Bill Kirkup reflected on this in his investigation into East Kent Hospitals, and decided not to make detailed policy recommendations: “I do not think that making policy on the basis of extreme examples is necessarily the best approach; nor are those who carry out investigations necessarily the best to do it. More significantly, this approach has been tried by almost every investigation in the five decades since the Inquiry into Ely Hospital, Cardiff, in 1967–69, and it does not work.”[1] As a consequence, the report suggested four areas for action that Trusts themselves can take to drive improvement. These are: Kind and compassionate care. Teamwork with common purpose. Identifying poor performance. Organisational oversight and response to challenge. We took these four areas as the starting point for our recent Collection: Maternity services: evidence to support improvement. We drew together research that would give Trusts a firm evidence base for improvement. When we engaged with stakeholders, they were particularly grateful for evidence on how to identify poor performance and on organisational oversight; these are frequently taken for granted in recommendations for best practice. Identifying poor performance I was struck by the basic challenge created by the poor quality of medical certificates of stillbirth: 80% contain an error, and 56% an error that would alter its interpretation. There are opportunities to generate richer learning from data readily available. For example, from complaints. Learning could be enhanced through: A reliable and meaningful coding system to classify complaints; for example, according to severity and the type of concern. Guidelines and training for the staff coding complaints. A centralised informatics system to capture and analyse complaints data. Bringing together and comparing complaints data with other sources of patient feedback and incident reporting (triangulating). A repeated message was the need to triangulate data. For example, the rate of caesarean sections alone is not a meaningful indicator of the quality of a service. A combination of performance data with patient feedback and other types of feedback can help interpret the statistic. There was also a need to ensure that recommendations from local audits and reviews were acted upon. Board oversight and response to challenge A key finding from many investigations into failures of care is the lack of oversight and understanding by the board. Donna Ockenden in her report said: “This meant that consistently, throughout the review period, lessons were not learned, mistakes in care were repeated, and the safety of mothers and babies was unnecessarily compromised as a result.”[2] A recent NIHR study of boards[3] identified five key roles for effective hospital boards: Conscience of the organisation – setting and reinforcing values. Shock-absorber – helping determine local priorities in a complex policy and regulatory environment. Diplomat – managing relationships across the local health economy. Sensor – scrutinising organisational performance to drive improvement. Coach – setting direction while providing support to staff. The study argues that effective boards take on all of these roles. This resonates with the findings from the East Kent and other investigations, in which the boards demonstrated weaknesses particularly in the roles of conscience, sensor and coach. Boards need to ensure that the voice and experience of both clinical staff and patients are heard and understood. Their involvement is a key factor in mature and high-quality improvement systems. Conclusion Maternity care aims always to be safe, effective and responsive. For the great majority, pregnancy and childbirth is a positive and happy experience that culminates in a healthy mother and baby. But on the rare occasions when things go wrong, the effects are life changing. We hope the evidence we brought together in our Collection will help hospitals to drive improvement and avoid devastating outcomes. References Kirkup B. Independent report. Maternity and neonatal services in East Kent: 'Reading the signals' report. Department of Health and Social Care, October 2022. Ockenden D. Independent report. Final report of the Ockenden review. Department of Health and Social Care, March 2022. Chambers N, et al. Roles and behaviours of diligent and dynamic healthcare boards. Health Services Management Research 2020;33(2):96-108. doi:10.1177/0951484819887507.
  4. News Article
    Failing mental health services that do not improve, whether run by private firms or the NHS, could be shut, a Care Quality Commission (CQC) chief has said. It follows the watchdog judging as "inadequate" three child wards at the Priory Group's biggest hospital. The wards at Cheadle Royal, near Manchester, "did not always provide safe care", the CQC found. The unannounced inspection of Cheadle Royal took place earlier this year "in response to concerns about safety". BBC News first reported in January three women had died at the hospital last year, although not in the wards inspected for this report. The CQC's new director of mental health services, Chris Dzikiti, said he was determined to drive up standards in all units and warned he will close services who fail to improve. Read full story Source: BBC News, 31 May 2023
  5. News Article
    After health inspectors considered closing a maternity unit over safety fears, the BBC's Michael Buchanan looks at a near-decade of poor care at East Kent Hospitals NHS Trust. "I've been telling you for months. The place is getting worse." The message in February, which Michael received from a member of the maternity team, was stark but unsurprising. In a series of texts over the previous few months, the person had been getting increasingly concerned about what was happening at the East Kent trust. The leadership is "totally ineffective" read one message. "How long do we have to keep hearing this narrative - we accept bad things happened, we have learned and are putting it right. Nothing changes." Friday's report from the Care Quality Commission (CQC) is unfortunately just the latest marker in a near-decade of failure to improve maternity care at the trust. The revelation that inspectors considered closing the unit at the William Harvey Hospital in Ashford comes nine years after the trust's head of midwifery made a similar recommendation for the same reasons - that it was a danger to women and babies. The failure to act decisively then allowed many poor practices to continue. Read full story Source: BBC News, 28 May 2023
  6. Content Article
    The lessons in this book were gathered while integrating human and organisational performance principles and practices at multiple biopharmaceutical companies and manufacturing sites—real-time experiences with frontline workers, support staff, and leaders. Do Quality Differently offers practical guidance for biopharmaceutical manufacturing plants and beyond—anywhere managing risk is paramount. Clifford Berry and Amy Wilson share a recent presentation that summarise key points from the book: HOP Integration - Berry Wilson.pdf
  7. News Article
    Health inspectors considered shutting down a maternity unit earlier this year over safety concerns. The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent. Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust. The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place. Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected. Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down." She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked. "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right. "The problems that are revealed are so fundamental that we have to do things differently." Read full story Source: BBC News, 26 May 2023
  8. News Article
    Pregnant women and new mothers are facing wide variation in access to mental health support, new figures suggest, as NHS England admits national performance on a key long-term plan goal to expand services is ‘over a year behind trajectory’. Analysis of access rates for perinatal mental health services from NHS Digital shows the rates of women accessing support within the past 12 months range from 3.7 per cent in Humber and North Yorkshire to 15 per cent in Shropshire, Telford and Wrekin ICS. The long-term plan target is for 66,000 women per year to be accessing specialist perinatal services, which can help with conditions such as post-partum psychosis, by March 2024. NHSE admitted in its papers that “although access is increasing, performance remains over a year behind trajectory”. Read full story (paywalled) Source: HSJ, 25 May 2023
  9. News Article
    Patients spent up to 25 hours on trolleys in corridors waiting for treatment and in some cases were left lying on "urine-soaked sheets" and in another on a "blood-stained pillow for several hours" at the Royal Infirmary of Edinburgh. Healthcare Improvement Scotland (HIS) inspectors also raised concerns over fire safety in the overcrowded A&E after two visits to the hospital - the first of which was carried out between February 20 to 22 and a further unannounced follow-up in March. The watchdog found "multiple systemic failures" in a report published on Thursday but NHS Lothian said a major improvement drive was already underway. The health board added that the hospital was had just endured its busiest winter on record ahead of the inspections. At the time of the inspection, the emergency department was on some days operating at over three times its capacity. The report described this as unsafe and a "fire safety risk" with the evacuation plan in place at the time not reflecting the "significant" impact of overcrowding. Read full story Source: The Herald, 18 May 2023
  10. News Article
    An ‘outstanding’ trust’s Care Quality Commission rating has been dropped to ‘requires improvement’, after inspectors found potential safety risks and a disconnect between board and ward. A highly critical report on University Hospitals Sussex Foundation Trust also downgraded its well-led rating to “inadequate” and recommended the trust be placed in segment four – the bottom tier – of NHS England’s system oversight framework. Its main tertiary centre – the Royal Sussex County Hospital – was also rated “inadequate”, including for safety. Deanna Westwood, Care Quality Commission’s director of operations in the South, said “staff and patients were being let down by senior leaders, especially the board, who often appeared out of touch with what was happening on the wards and clinical areas and it was affecting people’s care and treatment”. Read full story (paywalled) Source: HSJ,12 May 2023
  11. News Article
    Up to 10 junior doctor posts will be reinstated at a small district general hospital after regulators agreed it had improved its learning environment. In 2021, Health Education England removed 10 doctors from Weston Hospital over concerns they were being left without adequate supervision on understaffed wards. The unusual move prompted University Hospitals Bristol and Weston Foundation Trust to launch a “quality improvement approach” to improve its learner and clinical supervision environment. The regulator said the trust had made significant improvements that included: Better staff engagement with the trust leadership at all levels. Better clinical supervision, particularly around shift handovers and senior oversight of clinical decisions. Better learner experience in new training settings in rheumatology and intensive care medicine. Read full story (paywalled) Source: HSJ, 10 May 2023
  12. News Article
    Maternity services at a trust in Staffordshire have been rated as 'requires significant improvement' by the Care Quality Commission (CQC). University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely. It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be. Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services. The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage. Read full story Source: ITV News, 28 April 2023
  13. News Article
    NHS England has demanded recovery plans from six systems with a poor record on delivering urgent cancer checks. NHS England has told the chief executives of the six integrated care boards they must “present and deliver a plan” to make more use of their diagnostic facilities for patients who need urgent cancer checks. The “facilities” referred to are all community diagnostic centres. The six were selected because they diagnosed or ruled out fewer than 70% of urgent cancer referrals within 28 days during February. This benchmark is known as the “faster diagnostic standard”. A letter to the chief executives said: “improving waiting times for patients referred for urgent suspected cancer will be a critical priority for the NHS over the coming year”. It adds: “it is essential… our national investments in diagnostic capacity are more clearly prioritised for patients being investigated for urgent suspected cancer”. Read full story (paywalled) Source: HSJ, 28 April 2023
  14. News Article
    NHS trusts have been given targets to increase elective activity that range from 103% of pre-pandemic levels to nearly 130%, internal data seen by HSJ reveals. The wide gap between the targets, which are based on past performance and reflect the value of activity carried out, indicate the slow pace of recovery at many trusts last year. Forty trusts have been set the least ambitious target, to deliver 103% of pre-covid activity levels in 2023-24, including Leeds Teaching Hospitals, Barts Health, and University Hospitals Birmingham. All providers were supposed to deliver at least 104% of pre-covid activity last year, but few managed to achieve this, with emergency pressures, the impact of covid and flu, and workforce problems hampering efforts to ramp up activity. Amanda Pritchard has previously admitted the health service would have to “re-profile” the trajectory to achieving 130% of pre-covid activity levels by 2025. Read full story (paywalled) Source: HSJ, 20 April 2023
  15. News Article
    The NHS should abolish many of its national targets while shifting its focus towards preventive healthcare, according to a review by a former Labour health secretary. The study by Patricia Hewitt, commissioned by the government said that, while targets can help concentrate the minds of those responsible for a service, having too many makes them less effective. It comes at a time when record numbers of people are on NHS waiting lists and as the health service in England continues to miss targets on A&E waits, the speed of ambulance responses, and cancer treatment times. The review sets out new targets and failing to provide adequate funding for new initiatives makes it far harder to plan new services and recruit staff. It adds that an excessive focus on hitting targets by managers can lead to “gaming” of the targets and a “disastrous neglect of patients themselves”. Read full story Source: The Guardian, 3 April 2023
  16. News Article
    NHS trusts have been given until 2027-28 to employ enough midwives to meet safe staffing requirements, NHS England’s new maternity delivery plan has said. The three-year delivery plan for maternity and neonatal services sets out to “make maternity and neonatal care safer, more personalised and more equitable for women, babies and families”. It says: “Trusts will meet establishment [requirements] set by midwifery staffing tools and achieve fill rates by 2027-28, with new tools to guide safe staffing for other professions from 2023-24.” The plan follows a series of high-profile maternity scandals in the NHS at Shrewsbury and Telford, East Kent, Morecambe Bay and an ongoing independent review by Donna Ockenden into Nottingham University Hospitals Trust. The Care Quality Commission has highlighted a string of other concerns across the NHS. Read full story Source: HSJ, 31 March 2023
  17. News Article
    Plans for integrated care systems (ICSs) to be given Care Quality Commission (CQC) ratings are on hold, and no ratings will be issued until summer 2024 at the earliest, HSJ understands. The government had previously said ICSs would be given ratings – after pressure from Jeremy Hunt, then Commons health committee chair and now chancellor – and there was an expectation the process would begin next month. However, while legislation says the CQC will review and assess ICSs, it does not require it to give ratings. HSJ understands the Department of Health and Social Care supports the CQC beginning early work on assessing ICSs shortly, but does not plan to sign off on ratings being issued, nor set any date for that to happen. It means that, at the very earliest, more detailed reviews leading to ratings could happen from spring/summer 2024. One source with knowledge of the decision said there was not strong support for ratings work to start, and the CQC still needed to do a lot of work to adapt its approach to ICSs. Read full story (paywalled) Source: HSJ, 27 March 2023
  18. News Article
    Healthgrades recognised 864 US hospitals with its 2023 Patient Safety Excellence Awards and Outstanding Patient Experience Award. Only 83 of those hospitals received both awards. The dual recipients spanned 28 states. Texas had the most dual recipients with 12 honorees — including three Baylor Scott and White Health hospitals. Read full story Source; Becker's Hospital Review, 14 March 2023
  19. News Article
    Which trusts receive the highest recommendations from staff as a place to work? HSJ has analysed the full results of today’s 2022 NHS Staff Survey for general acute and acute/community trusts. HSJ has also analysed the results for mental health trusts and ambulance and community trusts. More than 630,000 staff responded to the NHS staff survey between September and December 2022 – a 46% response rate, down from 48% in 2021. Nationally, across all trust types, 57.4% said they would recommend their organisation as a place to work in 2022. That was down from 59.4% in 2021, and from 63.4% in 2019. Read full story (paywalled) Source: HSJ, 9 March 2023
  20. News Article
    Progress being made on tackling the hospital waiting backlog will be put at risk by next week's junior doctors' strike, NHS bosses are warning. NHS England medical director Prof Sir Stephen Powis said there had been huge achievements over the winter. But he said it was inevitable the 72-hour walkout in England, which starts on Monday, would have an impact. It comes as the annual NHS staff survey shows a falling number happy to recommend the care at their service. The poll found 63% would be happy to see a friend or relative treated - down by five percentage points in the past year and 11 over two years. Meanwhile, latest performance data shows NHS emergency services are continuing to miss their targets, although the situation is not getting worse. Dr Tim Cooksley, president of the Society for Acute Medicine, said despite the situation not getting worse it still presented a "damning" picture, and warned it was "increasingly causing harm to patients". Read full story Source: BBC News, 9 March 2023
  21. News Article
    England’s care regulator has been accused of failing to keep private nursing home residents safe after a family alleged a delay in exposing serious risks led to a loved one’s painful premature death. Relatives of Bernard Chatting, 89, said they relied on a “good” rating from the Care Quality Commission when they moved him into a £1,200-a-week home in Dorset. But after he experienced care so unsafe he ended up in hospital and died a few weeks later, it emerged the CQC already knew the home was failing badly. The case comes as CQC’s traffic light ratings become increasingly important for people looking to place relatives in England’s 17,000 care homes amid a staffing and funding crisis which experts fear could increase the risk of maltreatment of the most vulnerable citizens. The ratings from inadequate to outstanding are one of the few ways that families can check care standards. “We wouldn’t have sent Dad there if we knew,” said Chatting’s son-in-law, Phil Davenport. “It is beyond my understanding how the CQC inspect, have serious concerns, and yet not advise the public more quickly. Read full story Source: The Guardian, 8 March 2023
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